Get 877 251 5896

Filling out the 877 251 5896 form online is an important process for managing prior authorizations in healthcare. This guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently.

Follow the steps to complete the 877 251 5896 form online

1. Press the ‘Get Form’ button to access the form and display it in your document editor.
2. Begin by entering the patient's first and last name in the designated fields for patient information.
3. Provide the patient's ID number and date of birth, ensuring accuracy to avoid delays.
4. Input the diagnosis and the corresponding ICD code related to the patient's condition.
5. Fill in the prescriber information, including their name, DEA/NPI number, phone number, and fax number.
6. Insert the prescriber’s address, state, and ZIP code for proper identification.
7. Specify the medication and strength being requested, along with the quantity needed and days of supply.
8. Detail any other medications or therapies that have been tried, and include reasons for any failures, as well as additional information deemed important for the review.
9. The prescriber must sign the form, including their office contact name, date, and phone number to validate the submission.
10. Finally, review all the provided information for accuracy, then save your changes, download, print, or share the completed form as needed.

Complete the 877 251 5896 form online today for efficient prior authorization management.